Patient First Name:
Patient Last Name:
Date of request:
Date of Birth:
Release records to:
Phone number (of the person to receive records):
Email (of the person to receive records):
Address (of the person to receive records):
I request and authorize TC Orthodontics to release the information specified below to the organization, agency, or individual named in this request.
Information Requested:
Purpose or need for which information is to be used:
I certify that this request has been made voluntarily and that the information given above is accurate to the best of my knowledge. I understand that I may revoke this authorization at any time, except to the extent that action has already been taken to comply with it. Without my express revocation, this consent will automatically expire upon satisfaction of the need for disclosure.
Name of patient or legal guardian if under age 18 requesting release: